1. Numbers Make the World Go Round: Using Data to Drive Change May 25th, 2012 Presented by: T. Rollefstad SIA Safer Healthcare Now!, CPSI

2. We’ve got the data so now what? Session One

3. Where are we At and Where are we Going? Morning Session 1 – Describe some methods to drill into the data for a focus – Identify some next steps to use data for action – Learn a method for making rapid change Session 2 – Learn to apply a method for rapid change – Understand how to build knowledge from testing Afternoon Session 3 – Understand when to move from testing to implementation – Create a plan for next steps Session 4 – Explore in dialogue, several topics relevant to making change

4. Sourced from: NSW Department of Health (2002). Easy Guide to Clinical Practice Improvement (www.health.nsw.gov.au/quality/pdf/cpi_easyguide.pdf) The improvement process D PA S 3 Intervention Phase Diagnostic Phase 2 1 Project Phase 4 5 Sustaining Improvement Phase Impact Phase Project mission Project team Conceptual flow of process Customer Grid Data -Fishbone -Pareto chart -Run charts -SPC charts 2 months Plan a change Do it in a small test Study its effects Act on the result 2 months 1 month Annotated run chart SPC charts D P A S D P A S D P A S D P A S Ongoing monitoring Outcome Future plans 68% have selected a focus 63% have recruited a team 45-50% have completed a charter and begun testing

6. Diving into the Issues What questions & methods did you use in trying to drill into your data to find a focus? How did you choose the team members to work with you? How did you gain support for your work?

7. Getting MORE information Table Talk – Pick ONE Share with the table next to you: What questions & methods did you use in trying to drill into your data to find a focus? How did you choose the team members to work with you? How did you gain support for your work ? Debrief

8. 1. Project Phase “getting organized” i.decide on process that needs improving ii.form teams iii.write an aim statement iv.consider appropriate measures

9. AIM Statements Should be SMART Specific Measureable Appropriate Result oriented Time scheduled To reduce the rate of infections in joint replacement surgery to less than 1% within 12 months

10. 2. Diagnostic Phase Collect evidence and diagnose problem Determine the cause Use tools to identify and organize information

11. Tools: identify and organize process flow chart brainstorming patient focus group nominal group technique tally chart observation

12. Organize information Affinity diagram Pareto chart Histogram Graphs of current data-run and statistical process control charts (SPC) Huddles Cause and effect diagram

13. Pareto Chart Observations

14. 3. Intervention Phase Model for Improvement ACTPLAN DOSTUDY Langley, Nolan, Nolan Norman & Provost 1999 What are we trying to accomplish? How we will know that a change is an improvement? What change can we make that will result in an improvement?

15. Test Cycles Act What changes are to be made? Next cycle? Plan Objective Questions and predictions (why) Plan to carry out the cycle (who, what, where, when) Study Complete the analysis of the data Compare data to predictions Summarize what was learned Do Carry out the plan Document problems and unexpected observations Gather key data

16. How BIG shall we go?

17. PDSA cycle PDSA cycles – single test Changes that result in improvement Hunches, theories and ideas A S D P A S D P A S D P A SD P Sourced from: NSW Department of Health (2002). Easy Guide to Clinical Practice Improvement (www.health.nsw.gov.au/quality/pdf/cpi_easyguide.pdf)

18. From Improvement to Spread Spreading a change to other locations Developing a change Implementing a change Testing a change ActPlan StudyDo Theory and Prediction Test under a variety of conditions Make part of routine operations Robert Lloyd

19. Fast Forward PDSA Session Two

20. Pareto Chart Observations

21. Catheters in too long: Ideas to try Include catheter necessity in daily nursing assessments & shift change Develop nursing protocols to allow removal if criteria met Implement automatic stop orders for 48-72 hrs after insertion Place reminders (stickers) in patient order sheets requiring continuation of catheter order Use alerts in computerized ordering systems to indicate presence of a catheter & require documentation for continued need How-To-Guide: Prevent Catheter-Associated Urinary Tract Infections. Cambridge, MA: IHI; 2011. (Available at www,ihi.org)

22. Test Cycles Act What changes are to be made? Next cycle? Plan Objective Questions and predictions (why) Plan to carry out the cycle (who, what, where, when) Study Complete the analysis of the data Compare data to predictions Summarize what was learned Do Carry out the plan Document problems and unexpected observations Gather key data

25. Huddle Group in the Fish Bowl Instructions: 1.Choose an idea to test 2.Complete the questions for the PDSA planning on the flip chart 3.Discuss result in terms of your unit 4.Record answers to the Study of that result 5.Record the answers to the Act – change, adopt, abandon?

26. Observer Group Outer Ring Instructions: 1.Was the prediction clear? 2.Was the plan clear? W5 3.What did you learn in the study? 4.How would you modify the test?

27. Catheters in too long: Ideas to try Include catheter necessity in daily nursing assessments & shift change Develop nursing protocols to allow removal if criteria met Implement automatic stop orders for 48-72 hrs after insertion Place reminders (stickers) in patient order sheets requiring continuation of catheter order Use alerts in computerized ordering systems to indicate presence of a catheter & require documentation for continued need How-To-Guide: Prevent Catheter-Associated Urinary Tract Infections. Cambridge, MA: IHI; 2011. (Available at www,ihi.org)

28. Fish Bowl Debrief #1 What struck you about the planning portion? How did the teams study the “do” observations? What might you measure? How might you change this test?

29. Six Outer Ring volunteers for next fishbowl

30. Observer Group Outer Ring Instructions: 1.Was the prediction clear? 2.Was the plan clear? W5 3.What did you learn in the study? 4.How would you modify the test?

31. Fish Bowl Debrief #2 What struck you about the planning portion? How did the teams build on their learning? What might you measure? How might this testing work in your area?

32. Session Three Moving from Testing to Implementation

33. From Improvement to Spread Spreading a change to other locations Developing a change Implementing a change Testing a change ActPlan StudyDo Theory and Prediction Test under a variety of conditions Make part of routine operations Robert Lloyd

36. Power of Testing CHAT CLAVARDER

37. Develop, Test and Implement Degree of belief that the change will result in improvement High Developing a Change Testing a Change Cycle 1, 2, 3… Implementing a Change A successful change Change still needs further testing. There is a risk of implementing at this stage. Unsuccessful proposed change Low Moderate Source: Langley, et al. The Improvement Guide

38. Testing and Implementation Similarities: PDSA cycles Building knowledge Predictions Data Differences: Testing is temporary, implementation is permanent Support processes Expectations of failure Social impacts and resistance Balancing measures

39. IMAGINE 1 YEAR FROM NOW What does fully implemented look like?

40. 4. Impact and Implementation Sourced from: NSW Department of Health (2002). Easy Guide to Clinical Practice Improvement (www.health.nsw.gov.au/quality/pdf/cpi_easyguide.pdf) Impact and implementation phase Implement the changes Measure impact Annotated run chart SPC charts Other graphs

41. 5. Sustaining Improvement 1.Once an intervention has been introduced, the intervention and any improvements need to be sustained. 2.This may involve: Standardization of existing systems and processes Documentation of policies, procedures, protocols and guidelines Measurement and review of interventions to ensure that change becomes part of ‘standard’ practice Training and education of staff Sustaining Improvement Phase Sustain the gains Standardization Documentation Measurement Training Sourced from: NSW Department of Health (2002). Easy Guide to Clinical Practice Improvement (www.health.nsw.gov.au/quality/pdf/cpi_easyguide.pdf)

43. Leading Your Change Planning your next steps

44. Work Plan Exercise Take 30 min to document your next steps and tests using the work sheet provided Report out one of your planned next steps or tests

45. Tanis Rollefstad, RN, BN, MACT candidate Safety & Improvement Advisor SHN, CPSI Tanis.rollefstad@hqca.ca